Major US report sits on the fence about e-cigarettes

A major US review of e-cigarette evidence just released says e-cigarettes aren’t able to be easily categorised as “either beneficial or harmful”.

January 25, 2018

A major US review of e-cigarette evidence just released says e-cigarettes aren’t able to be easily categorised as “either beneficial or harmful”.

The report, sponsored by the US Food and Drug Administration (FDA) and carried out by the National Academies of Sciences, Engineering and Medicine, found switching from conventional cigarettes to e-cigarettes can reduce smoking-related illness.

But it also found that while e-cigarettes were likely to be far less harmful than conventional cigarettes they were not without health risks and that e-cigarette use by youth increased the risk of youth transitioning to smoking cigarettes.

The committee conducting the study identified and reviewed 800 peer-reviewed scientific studies and concluded that, to date, whether e-cigarettes had an overall positive or negative impact on public health was still unknown. “More and better research on
e-cigarettes’ short- and long-term effects on health and on their relationship to conventional smoking is needed to answer that question with clarity,” said the report (see summary of findings below).

“E-cigarettes cannot be simply categorized as either beneficial or harmful,” said David Eaton, chair of the committee that wrote the report, and dean and vice provost of the Graduate School of the University of Washington, Seattle. “In some circumstances, such as their use by non-smoking adolescents and young adults, their adverse effects clearly warrant concern. In other cases, such as when adult smokers use them to quit smoking, they offer an opportunity to reduce smoking-related illness.”

In New Zealand the previous Government announced in late March 2017 that it was planning to change legislation to allow the legal sale of nicotine and non-nicotine e-cigarettes and e-liquid (to people aged 18 years and over) in normal retail outlets.

Health Minister David Clark has made Associate Minister of Health Jenny Salesa responsible for tobacco control policy and services and a decision is yet to be announced on whether legislation will be introduced to parliament this year to allow the sale of nicotine e-cigarettes.

The Ministry of Health put out a position paper in October 2017 stating it believed e-cigarettes were lower risk than smoking, though not risk free, and could ‘contribute’ towards reaching the Smokefree 2025 goal.

The Public Health Consequences of E-Cigarettes consensus study report offers conclusions about e-cigarette use and a range of health impacts, including the following, and it notes the strength of the evidence for each conclusion:

Exposure to nicotine
There is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on the characteristics of the device and the e-liquid, as well as on how the device is operated. There is substantial evidence that nicotine intake from e-cigarettes
among experienced adult e-cigarette users can be comparable to that from conventional cigarettes.

Exposure to toxic substances
There is conclusive evidence that in addition to nicotine, most e-cigarettes contain and emit numerous potentially toxic substances. There is substantial evidence that except for nicotine, exposure to potentially toxic substances from e-cigarettes (under typical
conditions of use) is significantly lower compared with conventional cigarettes.

Dependence and abuse liability
There is substantial evidence that e-cigarette use results in symptoms of dependence on e-cigarettes. There is moderate evidence that risk and severity of dependence is
lower for e-cigarettes than for conventional cigarettes. There is moderate evidence that variability in the characteristics of e-cigarette products (nicotine concentration, flavoring, device type, and brand) is an important determinant of the risk and severity of
dependence on e-cigarettes.

Harm reduction
There is conclusive evidence that completely substituting e-cigarettes for conventional cigarettes reduces users’ exposure to many toxicants and carcinogens present in conventional cigarettes. There is substantial evidence that completely switching from regular use of conventional cigarettes to e-cigarettes results in reduced short term
adverse health outcomes in several organ systems. Use by youth and young adults
There is substantial evidence that e-cigarette use by youth and young adults increases their risk of ever using conventional cigarettes.

Secondhand exposure
There is conclusive evidence that e-cigarette use increases airborne concentrations of particulate matter and nicotine in indoor environments compared with background levels.
There is moderate evidence that second-hand exposure to nicotine and particulates is lower from e-cigarettes compared with conventional cigarettes.

Cancer
There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans. (An intermediate cancer endpoint is a precursor to the possible development of cancer; for example, polyps are lesions that are
intermediate cancer endpoints for colon cancer.) There is limited evidence from animal studies using intermediate biomarkers of cancer to support the hypothesis that long-term e-cigarette use could increase the risk of cancer.

Respiratory effects
There is no available evidence whether or not e-cigarettes cause respiratory diseases in humans. There is moderate evidence for increased cough and wheeze in adolescents who use e-cigarettes, and an increase in asthma exacerbations.

Injuries and poisonings
There is conclusive evidence that e-cigarettes can explode and cause burns and projectile injuries. Such risk is significantly increased when batteries are of poor quality, stored improperly, or are being modified by users. There is conclusive evidence that intentional or accidental exposure to e-liquids (from drinking, eye contact, or skin contact) can result in
adverse health effects such as seizures, anoxic brain injury, vomiting, and lactic acidosis.
There is conclusive evidence that intentionally or accidentally drinking or injecting e-liquids can be fatal.

Reproductive and developmental effects
There is no available evidence whether or not e-cigarettes affect pregnancy outcomes.
There is insufficient evidence whether or not maternal e-cigarette use affects fetal development.

Not ignoring “just a smoker’s cough” and other symptoms could see more of the 2000 Kiwis diagnosed with lung cancer each year living longer and better quality lives. FIONA CASSIE talks to lung cancer and respiratory nurse specialists about how nurses can play a part.